General Physical Examination



Definition: -
Physical Examination is a head to toe review of body systems that offer objective information about the client.
                                  OR
It is a process to gather comprehensive, pertinent assessment data by examining all the body parts from head to toe to assess the clients physiological functioning.

Purposes: -
1.     To ascertain the clients level of health & physiological function.
2.     To identify factors placing the client at risk.
3.     To confirm alterations disease as inability to perform the activities of daily living.
4.     To identify the need for additional testing or examination.
5.     Gather baseline data about the client’s health status.
6.     Supplement, confirm or refuel data obtained in the history.
7.     To identify & confirm Nursing diagnosis.
8.     Make clinical judgments about a client changing health status management.
9.     To evaluate the outcomes of treatment and therapy.

Preparation for Examination:-
1.     Patient : -
·        The patient should be explained well about the procedure.
·        The patient’s doubts should be classified.
2.     Nurse : -
·        Nurse should be confident, calm, organized & competent at the bedside.
·        Nurse must demonstrate respect for the client’s apprehension.
·        Nurse should review the agencies assessment form before meeting the client.
3.     Environment : -
·        Provide privacy to the patient.
·        The room should be quiet, warm, without draft & well it.
·        Avoid any kind of interruptions during the procedure.

4.     Equipments : -
The instruments used in physical examination should be
-         Easily accessible.
-         Clean or sterile.
-         In proper working order
-         Organized for their sequence of use.
-         The equipment that will touch the patient should be warmed before use by examiner’s hand or warm water.
A tray containing: -
1.        Aromatic substances like coffee, juices etc.
2.        Cotton balls in a bowl.
3.        Safety pin : - Disposable sharp object to assess pain, Sensory system
4.       Tape Measure: - Calibrated in cm to measure circumference.
5.       Tongue depressor: - Wooden tongue blade to inspect oral cavity & stimulate                  
        gag reflex to assess IX & X (glossopharyngeal & vagus) cranial nerves.
6.       Tuning fork: - Metal fork that vibrates when taped & is used to perform Rinne’s test to assess VIII (acoustic) cranial nerve.
7.       Lubricant: - Facilities insertion of instrument into body cavities.
8.       Drape: - covers exposed body parts. 
9.       Clean gloves.
10.  Laryngeal mirror – metal instrument with mirror to inspect pharynx & oral     cavity.
11.  Ophthalmoscope – lighted instrument attached to a battery tube to visualize the eye’s interior.
12.  Otoscope or Ear speculum: - Special ear speculum attached to an ophthalmoscope to visualize eternal & middle ear (eardrum).
13.  Penlight : - Flashlight to test papillary reaction to light & to assess III, IV & VI cranial nerves (coulometer , tracheal, & abducent) 
14.  Percussion Hammer – Instrument with rubber head to test reflexes.
15.  T.P.R. tray – To check Vital signs.
16.  Sphygmomanometer – To check blood pressure.
17.  Stethoscope – To do auscultation and to check B.P.

 Positioning for procedures: -
1)    Sitting – for head, neck, back, throat, lungs, heart, breasts, axillae and upper extremities examination and to check vital signs.
2)    Supine – for head, neck, anterior thorax, and abdominal examination also to check vital signs.
3)    Lithotomy – For examination of female genitalia & genital tract
4)    Sim’s lateral – for rectum & vagina examination
5)    Prone – for musculo-skeletal system assessment.
6)    Knee-chest position - Rectum and vaginal assessment.
    

     Techniques of physical Examination: -
     There are four techniques of physical examinations.
1.     Inspection.
2.     Palpation.
3.     Percussion.
4.     Auscultation.
    
1.     Inspection: - Inspection is the process of performing deliberate, purposeful observations in a systematic manner. Inspect each area of the body for size, Colour, shape, position & symmetry. Noting normal findings and any deviations from normal. The nurse uses her hearing & smelling along with observations to gather data throughout the assessment.

2.     Auscultation: - It is listening to internal body sounds to assess normal sound and detect abnormal sounds. It is done by use of stethoscope. Commonly assessed sound are Heart, Lungs, Abdominal and Vascular system.
    Techniques: -
·   Hold the diaphragm of stethoscope between index & middle finger firmly against the skin surface and use it to hear high pitched sound such as heart sound, lungs sound and blood pressure.
·   Place the bell lightly in contact with skin to hear low pitched sound such as murmur (a soft whisper, mumble, low sound) and bruit.
·   Auscultate the sound for characteristics
Ø    Pitch (high/low),
Ø    Intensity (soft/louder),
Ø    Duration (long/medium/short)
Ø    Quantity (Grunting/blowing/whisting/bhowing/whisting/snaping) 

     Stethoscope – picture / figure
                            Parts of stethoscope
                           The tubing should not be longer than 12 – 15 “

3.     Percussion: - It is a technique to assess tissue density by sound produced by tapping/ striking the skin, which determine the location, size and density of underlying structure to assess abnormalities. 
Techniques: -
1)    Direct percussion – Use one or two finger to percuss directly against a body surface
2)    Indirect percussion – Place the distal phalanx ( Tip of Finger) of the middle finger of your non dominant hand (Pleximeter)  on the clients skin over soft tissue
3)    Bend the middle finger of your dominant hand ( Plexor)  to create a hammer.
4)    Now strike plexor on pleximeter sharply and quickly .
5)    Percussion result in fine characteristics sound : -

S.N.
Sound
Characteristics
Areas
1.
Flatness
Soft, high pitched, short sound
Muscles
2
Dullness
Soft, moderate loud & pitched, medium duration. Due to less dense tissue and fluid filled tissue 
Liver & spleen

3
Resonance
Moderate to loud sound, Low pitched, longer duration. Due to air filled tissue
Lungs
4
Hyper Resonance
Very loud, Low pitched, Longer duration.
Produced by Over inflated Air filled lungs
Lungs
5
Tympany

Loud, high pitched, moderate duration.
Drum like quality due to enclosed, air containing structure.
Stomach and Bowel.

4.     Palpation: - Palpation is the assessment technique that user the sense of touch. The hands & finger are sensitive tools & can assess temperature, turgor, texture, moisture, vibrations & shape. The dorsum (back) surfaces of the hand & fingers are used for gross measure of temperature the palmer (front) surfaces of the finger & finger pads are used to assess texture and to assess vibration of lungs
Assess position, consistency, mobility, size, shape & skin turgor by lightly grasping tissue between the thumb & index finger.
     Techniques of Palpation: -
1.     Light palpation : - depress the underlying tissue approximately 1-2 cm (1/2”-3/4”)
2.     Deep Palpation: - 4-5 cm (11/2-2”) to determine the size & condition of underlying structure such as abdominal organs.
3.     Bimanual palpation – place one hand lightly on the client skin (sensing hand) and place the other hand (active hand) over the sensing hand to apply pressure the saving hand remain sensitive to underlying organ characteristics.  

5.     Oflaction – It is the use of the sense of smell to detect body order the sense of smell help defect abnormalities not readily recognized by others. 
For example - 1) smell of ammonia in urine suggest UTI
                       2) Strong musty odor from cast – a wound Infection
            








Sr.No.
Assessment Area
Client Position
Techniques
Equipment
What to observe
1
 General Survey
Standing Walking Sitting
Inspection Olfaction







Wt. Machine & Measurement Tap  Thermometer& Sphygmomanometer
a)    General appearance and behavior: - Apparent age, sex, race, health status, body build, posture, gait, any deformities movement & ROM.
           Skin – color and texture
           Dress, hygiene and grooming, body or breath odor
           Mental status:- sign of distress, affect, expression,   
           speech, memory, eye contact. Level of                 
            consciousness.
b) Height and Weight
c) Balance and co-ordination
d) Vital signs – T.P.R. , BP
2
Head and Neck

Sitting on edge of examination table

Inspection





palpation






Palpation




Inspection







Inspection












Inspection












Inspection






Palpation




Inspection







Inspection














Inspection


Palpation


Tap measure




Stethoscope












Sneller chart
Eye cover, pen



Penlight / pen

Penlight / pen













Ear specula Otoscope ( As per hosp. policy if allowed to use by Nurses)


Tuning fork  
( 512 Hz)



Penlight

Nasal specula

Penlight








Gloves,

Tongue blade,

Penlight


HEAD
1)      Inspect and palpate: skull size, shape, symmetry, tenderness, lesion and measure head circumference if abnormal size
2)      Inspect hair & scalp: Color, integrity hair distribution and texture. Presence of nits or lice hygiene.
3)      Palpate Temporal Arteries:  thickening, Tenderness, Auscultate for bruit if abnormality noted.
FACE
1)      Inspect symmetry , skin color , hair distribution
       facial movement ( CN V &VII ) Clenched jaws,                                                          
       eye brows .
2)      Palpate TMJ ( Temporo-Mendibular joint) , Nodules, Temporal & Masseter muscle ( CN-V)
3)      Test facial sensation for light , touch , pressure and pain (CN V) 
EYES
1)      Visual acuity ( CN- II)
2)      Visual fields (peripheral vision)  by moving one finger from center to peripheral(CN II)
3)      EOM, through six cardinal position of gaze ( CN III,IV,VI, VIII)
4)      Convergence (dilatation) and accommodation (constriction) of pupils (CN – III, IV, VI)
5)      Corneal light reflex ( CN – III, IV, VI)
6)      Inspection and Palpate external eye structures.
                                       i.   Eye brow symmetry , alignment
                                     ii.   Eye dash symmetry, hair distribution , direction of growth
                                   iii.   Eyelid position , blinking
                                   iv.   Eyeball symmetry
                                     v.   Conjunctiva and sclera color, texture, lesion, foreign bodies.
                                   vi.   Cornea textures, transparency (opaque in cataract), reflex.
                                 vii.   Pupil – symmetry, Color, Size, reaction to light and accommodation ( CN – III,IV,VI)
EARS
1)      Inspect & palpate external ear structure :
a)      Auricle symmetry, placement, skin integrity, color, mobility tenderness.
b)      Ear canal – skin intensity , obstruction , discharge , foreign body
c)      Tympanic membrane symmetry, color, landmarks scars, fluid.
2)      Hearing Acuity – Response to normal conversation
-          Weber’s Test for sound lateralization
-          Rinne’s test for air & bone conduction sound  (CN VIII)

NOSE And SINUSES
1)      Inspect and palpate external nose alignment : skin color, lesion, tenderness, discharge, nasal flaring
2)      Inspect vestibule - color, mucus membrane , septum alignment
3)      Inspect nasal canula for color, moisture,
4)      Septum for alignment, masses, perforation & alignment , exudates, inflammation
5)      Palpate and percuss frontal and maxillary sinuses for swelling & tenderness
6)      Sense of smell (CN – I) e.g. Coffee, spirit etc.

MOUTH AND PHARYNX
1)      Inspect & palpate – Lips & Oral mucosa for color, symmetry, texture , hydration, lesions,
2)      Inspect teeth & gums for hygiene, teeth alignment gum bleeding gum
3)      Inspect & palpate tongue & floor at Mouth for symmetry, color, tongue position and size, texture, mobility, tension etc.
4)      Tongue mobility strength ( CN IX, XII)
5)      Inspect oral cavity for ulcer, tension, redness, texture.
6)      Inspect tonsils and pillars for color, size, shape, Inspect pharynx for color, discharge, on post wall.
7)      Test gag reflux ( CN-IX, X) if swallowing impaired noted
8)      Note characteristics of Voice, ability to swallow (CN-IX, X)
9)      Note presence of breath odor.
10)  Test sense of taste (CN- VII, Ix) only if abnormality reported with sugar, salt, lemon juice, bitter.

NECK
1)      Inspect neck muscle symmetry, ROM, strength (CN – XI)
2)      Palpate and inspect over partial and submondibular salivary glands for swelling, tenderness.
3)      Palpate all cervical lymph nodes
4)      Inspect and palpate – Trachea and Thyroid gland for symmetry and alignment.
5)      Inspect jugular venous distension.

3.
Upper Extremities and Spine
Sitting on edge at examining table

Inspect



Palpation




















Reflex Hammer
UPPER EXTRIMETIES
1)      Inspect skin for lesion and palpate for turgor
2)      Inspect limb for alignment and symmetry
3)      Inspect fingernails and blench to test capillary refill, inspect clubbing
4)      Palpate peripheral pulses : brachial , radial, and ulnar and Pulse rate
5)      Inspect act palpate muscle group for size, symmetry & tone
6)      Evaluate & rate muscle strength.
7)      Inspect & palpate joints for swelling and tenderness.
8)      Assess ROM – Shoulder, elbow, wrist, and finger.



SPINE
1)      Test reflexes & rate response : biceps, triceps, brachioradialis
2)      Assess cerebellar function, finger to finger touch, hand supination & pronation.
4.
Posterior Thorax
Sitting on edge of table Nurse stand behind client
Inspection









Palpation
percussion

Auscultation




percussion






Measurement Tap 






Stethoscope
SPINE, RIBS, MUSCLES
1)      Inspect spine for alignment, palpate spine process for tenderness, inspect skin integrity.
2)      Inspect rib cage for symmetry, shape , movement with respiration
3)      Measure antero-posterior and lateral diameter
4)      Assess thoracic expansion (respiratory excursion)

LUNGS
1)      Observe respiratory Pattern
2)      Palpate tactile fremitus & respiratory excursion
3)      Percuss posterior & lateral thorax
4)      Measure diaphragmatic excursion
5)      Auscultate breath sound – post & lateral thorax
6)      Auscultate voice , sound , If fremitus abnormal


KIDNEYS
Percuss our cost – vertebral area for kidney tenderness  
5
Anterior thorax

Sitting on edge of table Nurse stand on right side of patient.






Sitting up & leaning forward 


Sitting with arm at sides Houdson hips, with arms raised over head

Inspection




Palpation percussion
Auscultation

Inspection

Palpation
Auscultation




Inspection




Palpation









Stethoscope
THORAX  and LUNGS
1)           Inspect skin integrity
2)           Observe respiratory pattern
3)           Inspect rib cage for movement on respiration,    
         symmetry shape & use of accessory muscles
4)           Palpate respiration excursion and tactile fremitus
5)           Percuss Anterior thorax
6)           Auscultate breath sound & voice fremitus.

HEART
1)           Inspect precardium for lift, heaves & apical   
         pulse
2)           Palpate precardium for thrills, apical impulse.
3)           Auscultate heart sound with client sitting up than     
         learning & for ward
4)           Assess heart rate and rhythm

BREASTS AND AXILLAE
1)      Inspect breast in 3 position for size, shape, symmetry, skin lesion and contour
2)      Inspect areole and nipple for size, shape , color, symmetry and lesion
3)      Inspect axillae for rashes , masses, lesion, pigmentation
4)      Palpate axillae for lymph nodes
5)      Palpate breast areole & nipples with client supine and arm behind head for lumps masses, consistency.
6
Abdomen
Supine position
Inspection Auscultation
Percussion palpation












Percussion




Percussion




palpation



palpation


Measurement Tap 

Stethoscope


Stethoscope
ABDOMEN ( GENERAL)
1)      Inspect skin integrity and characteristic striae, various pattern hair distribution, contour, symmetry, umbilicus, pulsation, peristalsis, rectus muscle and abdomen girth.
2)      Auscultate all 4 quadrants for bowel sounds
3)      Auscultate major arteries / vessels for bruit abdomen aorta, renal iliac and femoral arteries
4)      Auscultate over liver and spleen for peritoneal friction rub.
5)      Percuss all quadrants for mass and tenderness gastric bubble over bladder and spleen.
6)      Lightly palpate all quadrants for masses and tenderness follow by deep palpation.
7)      Assess for rebound tenseness over RLQ & LLQ.
LEVER
1)      Percuss liver size at RMCL (Right  Mid clavicle line)  and MSL ( Mid sternum line ) and mark border
2)      Measure liver span at RMCL and MSL
SPLEEN
1)      Percuss spleen size and if indicated Percuss for enlargement
AORTA
Palpate for area of pulsation in epigastrium.
KIDNEY
1)      Palpate Right and Left kidneys
2)      Blunt percussion over costo-vartibral area (post.) for tenderness.
INGULNAC AREAS
1)      Palpate femoral Arteries and pulse rate
2)      Palpate inguinal lymph nodes : note characteristics.
7
Lower Extremities

Inspection



Palpation



Palpation




LOWER EXTREMITIES : -
1)      Inspect skin for lesions., hair distribution
2)      Inspect limb for alignment and symmetry
3)      Inspect toenails and blanch to test capillary refill
4)      Palpate peripheral pulses palatial posterior tibial dorsalis pedis.
5)      Inspect for edema and palpate for pitting if present
6)      Palpate for phlebitis (Inflammation of vain) Varicosities. (Increased diameter of vein & decrease elasticity) measure circumferences of calve or thighs, if phlebitis present.
7)      Evaluate muscle strength; hips, quadriceps, ankles, toes & feet.
8)      Inspect and palpate joint for swelling tenderness and crepitus.
9)      Assess ROM; hip, knees, ankles, feet and toes
10)  Check Deep tendon reflexes (DTRs) Test patellar, Achilles and planter cutaneous reflex.

8
 General Neurolgical
Supine with eyes closed









Walking heel to toe

Hoping an each feet kne bends
Inspection

Cotton wisp

Sterile safty pin

Tuning fork
Key, Coin
SENALSORY FUNCTIONS
1)           Test perception of light touch over trunk, face &  
             neck
2)           Test perception of pain vs. pressure over face &         
         neck
3)           Test perception of vibration on toes & fingers
4)           Test object identification both hard
5)           Test graspism of both hand
6)           Test temperature perception. 
GROSS MOTOR AND BALANCE
1)      Inspect gait and balance white client walks on  heel to toe than on toes to heel
2)       Observe balance while client stands on one foot.
3)      Observe balance & Lower extremities strength while hops on the foot.
4)      Observe balance & strength while client perform shallow knee bands.
9
Male Genitalia  and Anus

Standing

.

Inspection

Groves worn  throughout
MALE GANITALIA
1)      Inspection pubic hair and skin for hair distribution, rashes, lesion, or parasites.
2)      Inspect penis: Shaft, prepuce (foreskin) Glans, urethral meatus and observe for any discharge.
3)      Inspect scrotum for size, symmetry, shape, swelling
ANUS
         Inspect perineal skin for integrity, color, rash, 
         lesion, fissures, ulcers, polyps, inflammation ,
         hemorrhoid 
10
 Female Genitalia and Anus

Dorsal recumbent

Inspection

Gloves worn throughout
FEMALE GENITALA
Inspect external genitalia
-          Monspubis for pubic hair distribution & texture
-          Perineal skin for color, lesion, irritation
-          Suspect labia majora & Minora for edema (swelling) and symmetry
-          Inspect clitoris for color, and presence of lesion.
-          Inspect urethral meatus for discharge, inflammation
ANUS
 Inspect perineal skin for integrity, color, rashes,     lesion, fissures, ulcer, polyps & hemorrhoid.

11
REFLEXS

Sitting on edge of table

Inspection

Hammer
DEEP TENDON REFLEXES (DTRs)
Biceps
i.     Flex clients arm up to 45º at elbow with palm  
            down.
ii.         Place your thumb in anticubital fossa at base of   
       biceps tendon and your finger at biceps muscle.
iii.       Strike triceps tendon with reflex hammer
Normal :  Flexion of arm at elbow

Triceps
i.             Flex clients arm at the elbow, holding arm across chest
ii.           Strike triceps tendon just above the elbow
Normal – Extension of Elbow.
Patellar –
i.      Have client sit with legs hanging freely over side     of table/chair or have client lie supine are support knee in a flexed 90 º position.
ii.     Briskly tap patellar tendon just below patella.
Normal – Extension of lower legs.
Achilles -
i.        Have the client assume same position as for patellar reflex.
ii.    Slightly dorsiflex client ankle by grasping toes in palm of your hand 
iii.  Strike Achilles tendon just above heel at ankle malleolus.
Normal – Planter flexion of foot.

             

ROLE OF NURSE AFTER THE EXAMINATION:- 

CARE OF PATIENT –
1)      After completing the assessment, give the client time to dress.
2)      The hospitalized client may need help with hygiene and retuning to bed
3)      When the client is comfortable, it helps to share a summary of the assessment finding.

RECORDING & REPORTING:-
1)      You may record finding from the physical assessment during the examination or at the end.
2)      Record the finding in available special form.
3)      Review all finding before assisting the client with discussing in above of a need to recheck any information or gather additional date any information or gather additional data.
4)      If the findings have serious abnormality the client’s physician should be consulted.

CARE OF EQUIPMENT AND ENVIRONMENT:-
1)      Support staff may be delegated to clean the examination area.
2)      Instrument and equipment used should be washed and replaced after disinfection practice
3)      If examination done on bedside, clear away soiled items from bedside table and change the bed linen if needed.
4)      Be sure to wash the hand after work.

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